In Ramathibodi hospital (1983-1997, N= 20) Indication for lung resection –Congenital cystic disease45% –Persistent pneumonia and/or 25% atelectasis with bronchiectasis –Lung abscess20% –Abnormal mass with 10% recurrent hemoptysis Srisan P. A thesis submitted for the diploma of thai subboard of pediatric pulmonology 1998.
Lung resection Pneumonectomy: Surgical removal of an entire lung Lobectomy: Surgical excision of a lobe Segmentectomy: Surgical excision of segment of lung Wedge resection: A surgical procedure to remove a triangle- shaped slice of tissue. It may be used to remove a tumor and a small amount of normal tissue around it
Preoperative evaluation Pulmonary function Calculation of predicted postoperative pulmonary function Measurement of gas exchange Exercise testing
Pulmonary function test FEV 1 <60%predicted was strongest predictor of postoperative complication DLCO
Current guidelines Preoperative FEV 1 >80%predicted can tolerate pneumonectomy Exertional dyspnea or coexistent interstitial lung disease DLCO Preoperative FEV 1 and DLCO > 80% predicted not need further testing Colice GL, et al. Chest 2007
Predicted postoperative PFTs Combination of Preoperative spirometry and quantitative perfusion lung scanning to estimate the degree of functional loss
Predicted postoperative PFTs FVC c = FVC preop x S x 5.26/100 FVC c = FVC calculated FVC preop = FVC pre operation S = segment left
Predicted postoperative PFTs FVC a = 0.109 + 1.185FVC c (R 2 = 91.30%, p <0.0001) FEV 1a = 0.006 + 1.138FEV 1c (R 2 =87.97%, p <0.0001) FEF 25-75a = -0.186 + 1.053FEF 25-75% (R 2 =70.32%, p <0.0001) Srisan P. A thesis submitted for the diploma of thai subboard of pediatric pulmonology 1998.
Current guidelines Increased risk for lung resection with predicted postoperative values for either FEV 1 or DLCO < 40% predicted Preoperative exercise testing is recommended Colice GL, et al. Chest 2007
Gas exchange P a O 2 ; not important predictor of postoperative complication P a CO 2 ; not correlate with postoperative complication Marshall MC, et al. Clin Chest Med 1993. Wyser C, et al. Am J Respir Crit Care Med 1999.
Cardiopulmonary exercise testing (CPET) Correlate with postoperative complication Maximal oxygen consumption (VO 2 max) VO 2 max < 15ml/kg/min or < 50%predicted correlated with postop complication 1 1 Walsh GL, et al. Ann Thorac Surg 1994.
Current guidelines VO 2 max < 10 ml/kg/min or VO 2 max < 15ml/kg/min and both predicted postoperative FEV 1 and DLCO < 40% predicted increase risk of perioperative death and complication Colice GL, et al. Chest 2007
Physiology of lung resection Olsen GN. Chest 1998.
Anatomic changes Immediately; –air fills the space previously occupied by lung –Chest tube is not inserted Over time; –Elevation of hemidiaphragm, hyperinflation of the remaining lung and shifting of mediastinum to postpneumonectomy space (PPS) –Fluid accumulating in PPS (2 rib space per day)
Anatomic changes –Complete opacification of hemithorax after pneumonectomy (3wks-7mo) Unexpected rapid accumulation of fluid hemorrhage, infection or chylothorax Vital organs shifted position
Anatomic changes Day 1 Day 2 Day 14 Day 30 Chae EJ, et al. RSNA 2006.
Early mortality 30 days mortality 2.4-11.6% Risk factors for early mortality –Right-sided pneumonectomy –Specific type of surgical resection –Underlying disease –Emergency surgery –The level of experience of surgeon
Postoperative pulmonary outcome FEV 1, FVC are decreased DLCO is decreased but normal corrected DLCO/lung volume ratio Lung compliance is decreased, airway resistance is increased Arterial oxygen saturation, PO 2, PCO 2 not changed
Postoperative cardiovascular outcome Right pneumonectomy –Rt.ventricular end diastolic volume is low but left ventricular function is normal Left pneumonectomy –Opposite Rt.pneumonectomy Smulders SA, et al. Ann Thorac Surg 2007.
Postoperative quality of life Quality of life scores (pain, physical function and dyspnea) decrease after pneumonectomy Lobectomy and wedge resection are normal Balduyck B, et al. Lung Cancer 2007.
Postoperative complication Hemorrhage complication: –Inadequate hemostasis of the bronchial artery or a systemic vessel in the chest wall –Infrequently, slipping of a ligature or an un- recognized injury is a cause –Bleeding related to coagulation is rare Re-exploration is indicated if –failed response to blood replacement –a large amount of blood in the hemithorax –persistent massive bleeding from the chest tube
Postoperative pulmonary complication Early complications: –Pulmonary edema, ARDS –Bronchopleural fistula –Postpneumonectomy empyema –Pneumonia of contralateral lung Late complications: –Postpneumonectomy syndrome –Late onset bronchopleural fistula –Infections
Postpneumonectomy pulmonary oedema (PPO) Incidence ~5% but high mortality >50% Histopathology: –The first 5 day; endothelial integrity lost with extravasation of fluid, protein and inflammatory cells into alveolar spaces –First few days; marked proliferation of fibroblasts and type II pneumocytes –After 10 days; interstitial and intraalveolar fibrosis, thrombotic and obliterative change Jordan S, et al. Eur Respir J 2000.
Postpneumonectomy pulmonary oedema (PPO) Jordan S, et al. Eur Respir J 2000.
Postpneumonectomy pulmonary oedema (PPO) Risk factors; –Fluid balance ? Jordan S, et al. Eur Respir J 2000.
Postpneumonectomy pulmonary oedema (PPO) A dog pneumonectomy model: –Higher fluid input and urine output not developing PPO if left heart filling pressure remained normal An intraoperative fluid input > 2L risk of PPO 1 Jordan S, et al. Eur Respir J 2000. 1 Parquin F, et al. Eur J Cardiothorac Surg 1996. “ Increased infusion of fluids in high permeability patients may be relevant in exacerbating or prolonging the clinical condition ”
Postpneumonectomy pulmonary oedema (PPO) Risk factors; –Fluid balance ? –Surgical technique ? Degree of parenchymal injury inflammatory reaction Duration of surgery does not be implicated Hayes JP, et al. Thorax 1995.
Postpneumonectomy pulmonary oedema (PPO) Risk factors; –Fluid balance ? –Surgical technique ? –Tidal volume ventilation ? Low tidal volume pressure limited technique can improve outcome –Age and preoperative lung function ? Not correlate
Postpneumonectomy empyema Early empyema; 10-14days after surgery, associated with bronchopleural fistula or /and esophagopleural fistula Late empyema; more than 3 months, infection (via hematogenous route) –S.aureus and P.aeruginosa are common
Postpneumonectomy pulmonary oedema (PPO) Onset: 1-3 days postoperative Clinical presentation: same as pulmonary edema, ARDS May be difficult to differentiate between PPO and pneumonia Jordan S, et al. Eur Respir J 2000.
Postpneumonectomy pulmonary oedema (PPO) Pathophysiology: –Panendothelial inflammatory vascular injury release of inflammatory mediators –Vasoconstrictor endothelins (ETs) lead to pulmonary vascular remodelling pulm. HT –Others; vascular obstruction and positive pressure ventilation Jordan S, et al. Eur Respir J 2000. Pulmonary vascular control
Postpneumonectomy syndrome (PPS) Valji AM, et al. Chest 1998.
Postpneumonectomy syndrome (PPS) Extrinsic compression of distal trachea and mainstem bronchus : Left( right ) PPS: (counter) clockwise rotation of great vessels and trachea→compression of right (left) main bronchus and right(left) pulmonary artery Shifting of the mediastinum and hyperinflation of remaining lung Valji AM, et al. Chest 1998.
Postpneumonectomy syndrome (PPS) Occur more than 6 months following surgery Progressive dyspnea, cough, inspiratory stridor and recurrent pneumonia PFTs: obstructive pattern (bronchial obstruction leads to decrease in flow rate and air trapping) Diagnosis: CXR, CT chest and awake fiberoptic bronchoscope Valji AM, et al. Chest 1998.
Postpneumonectomy syndrome (PPS) Surgical repositioning of mediastinum and filling of PPS with a non absorbable material –Saline solution-filled prosthesis and anterior pericardiorrhaphy Early diagnosis and treatment of PPS should prevent tracheobronchomalacia Valji AM, et al. Chest 1998.